Laparoscopic inguinal hernia repair in children using the percutaneous internal ring suturing technique – own experience

INTRODUCTION: Percutaneous internal ring suturing (PIRS) is a method of laparoscopic herniorrhaphy, i.e. percutaneous closure of the internal inguinal ring under the control of a telescope placed in the umbilicus. AIM: To evaluate the usefulness of the PIRS technique. MATERIAL AND METHODS: Fifty-five children (39 girls and 16 boys) underwent surgery using this method in our institution between 2008 and 2010. RESULTS: In 10 cases the presence of an open inguinal canal on the opposite side was also noted during surgery, and umbilical hernia was recognized in 2 patients. In 5 cases it was necessary to convert to the open surgery because of the inability to continue the laparoscopic procedure. In 1 case, male pseudohermaphroditism was diagnosed during surgery. Recurrent inguinal hernia required a conventional method of surgery in 1 child. Other children did not exhibit the characteristics of hernia recurrence. The inguinal canals were followed up with postoperative ultrasound examination in 29 children. In 23 children, the ultrasound examination showed no dilatation of the inguinal canal. In the other 6 children dilatation of the inguinal canal or the presence of fluid within the inguinal canal was observed during ultrasound. In 6 children symptoms such as swelling and soreness around the inguinal canal developed within 3 to 6 months after surgery. CONCLUSIONS: Inguinal hernia surgery using the PIRS procedure is an alternative, effective, minimally invasive method of surgery. Visualization of the peritoneal cavity allows for detection of other abnormalities, as well as for performing other procedures during the same session (such as closing the contralateral inguinal canal or umbilical hernia surgery)

Iatrogenic hemobilia in 10-year-old boy

Background: Hemobilia in children is a rare phenomenon which has been described mostly in the context of traumas. The descriptions of massive hemobilia in children after liver biopsy are a rarity in the scientific literature because there are only a few examples of it. Hemobilia rarely develops spontaneously. Generally, this is a complication after a blunt abdominal trauma or after medical (especially surgical) procedures. Correct diagnosis and treatment of hemobilia are essential, especially in the case of patients with severe - sometimes life-threatening - haemorrhage from biliary ducts. It should be remembered that the symptoms of hemobilia do not necessarily occur immediately after surgery or trauma. In some cases hemobilia occurs after a changeable, asymptomatic period of time. Case Report: We would like to present a case of a severe form of hemobilia caused by arterio-biliary fistula which developed incidentally after liver biopsy in a 10-year-old boy with chronic hepatitis B. Symptoms of hemobilia appeared on the seventh day after the diagnostic biopsy when the patient’s general condition began to deteriorate. The diagnosis of arterio-biliary fistula was established after angio-CT examination of the liver. A selective embolization of the right hepatic artery was carried out. Hemobilia in children is a rare phenomenon which has been described mostly in the context of traumas. The cases of massive hemobilia in children after liver biopsy are a rarity in the scientific literature because there are only a few examples of it. Hemobilia very rarely develops spontaneously. Generally, this is a complication after a blunt abdominal trauma or after medical (especially surgical) procedures. Conclusions: Correct diagnosis and treatment of hemobilia are essential, especially in the case of patients with severe - sometimes life-threatening - haemorrhage from biliary ducts. It should be remembered that the symptoms of hemobilia do not necessarily occur immediately after surgery or trauma. In some cases hemobilia occurs after a changeable, asymptomatic period of time

Laparoscopic Heminephrectomy for Duplex Kidney in Children—The Learning Curve

Objectives: Outcomes evolution during the learning curve of laparoscopic transperitoneal heminephrectomy in children with a duplex kidney.Materials and Methods: The data of 33 children, operated on between 2008 and 2017, with complicated duplex kidney, were subjected to a retrospective analysis. All patients were operated on by transperitoneal access using the laparoscopic technique. Patients were divided into two groups (1: subsequent operation 1–16, and 2: operations 17–33) to evaluate the learning curve.Results: There was no need for conversion. Total complications occurred in seven patients in Group 1 and 2 patients of Group 2 (p < 0.05). Two patients (6%) (both upper pole heminephrectomies) required reoperation to remove the ureter stump because of recurrent UTIs due to undiagnosed VUR to the stump (1 from each of Groups 1 and 2). Prolonged urine leakage (over 4 days) was observed in four patients (12%; all from group 1); in three patients, conservative treatment was successful, while the placement of a DJ catheter was needed in the fourth. A significant decrease of kidney function (>6%) in scintigraphy was observed in two of the 15 patients after the surgery. The time of surgery decreased from 140 (range 85–185) min in Group 1 to 125 (range 100–150) min in Group 2 (p < 0.05).Conclusions: Laparoscopic heminephrectomy is connected to the learning curve. Most complications occurred in the first 16 operations. With increasing experience, the time of operation decreased. In patients with reflux to the upper pole, referred for upper pole heminephrectomy, it is necessary to consider the removal of the ureter to the level of the vesicoureteral junction

Hydronephrosis in Children Caused by Lower Pole Crossing Vessels—How to Choose the Proper Method of Treatment?

Objectives: Assessment of the efficacy of intraoperative diagnosis between extrinsic and intrinsic UPJO in children. Assessment of the efficacy of laparoscopic vascular-hitch procedure in UPJO caused by lower pole crossing vessels (CV).Materials and Methods: Between 2008 and 2017, 47 laparoscopic procedures were performed with the CV discovered intraoperatively. CV were translocated cephalad, and the UPJ was carefully inspected. The Chapman's vascular hitch procedure was accomplished in the case of decreasing sizes of the pelvis and clear, visible peristalsis of the UPJ (31 patients). In the other cases, Anderson–Hynes (A-H) pyeloplasty with posterior translocation of the CV was performed (16 patients).Results: The median age at operation was 6 years (range 1–16) in VH and 6 years (range 2–17) in A-H (p = 0.4635). Prenatal dilatation of kidney was diagnosed in 18.7% of VH and 10% of A-H cases (p = 0.5474). Success was achieved in 16 (100%) patients in the A-H and in 29 (93.54%) in the VH groups. Two patients (6.5%) in VH required repeated surgery because of a misdiagnosed intrinsic obstruction. Median operation time in VH was 80 min (range 40–105) and was 105 (range 70–225) in A-H (p < 0.05).Conclusions: The intraoperative selection based on intraoperative pelvis and UPJ appearance after vessel transposition is sufficient in majority of cases. Laparoscopic vascular hitch seems to be effective and safe procedure, but can only be performed on carefully selected patients. In case of misdiagnosis, reoperation is possible with the same laparoscopic access

Artificial intelligence based surgical support for experimental laparoscopic Nissen fundoplication

BackgroundComputer vision (CV), a subset of artificial intelligence (AI), enables deep learning models to detect specific events within digital images or videos. Especially in medical imaging, AI/CV holds significant promise analyzing data from x-rays, CT scans, and MRIs. However, the application of AI/CV to support surgery has progressed more slowly. This study presents the development of the first image-based AI/CV model classifying quality indicators of laparoscopic Nissen fundoplication (LNF).Materials and methodsSix visible quality indicators (VQIs) for Nissen fundoplication were predefined as parameters to build datasets including correct (360° fundoplication) and incorrect configurations (incomplete, twisted wraps, too long (>four knots), too loose, too long, malpositioning (at/below the gastroesophageal junction). In a porcine model, multiple iterations of each VQI were performed. A total of 57 video sequences were processed, extracting 3,138 images at 0.5-second intervals. These images were annotated corresponding to their respective VQIs. The EfficientNet architecture, a typical deep learning model, was employed to train an ensemble of image classifiers, as well as a multi-class classifier, to distinguish between correct and incorrect Nissen wraps.ResultsThe AI/CV models demonstrated strong performance in predicting image-based VQIs for Nissen fundoplication. The individual image classifiers achieved an average F1-Score of 0.9738 ± 0.1699 when adjusted for the optimal Equal Error Rate (EER) as the decision boundary. A similar performance was observed using the multi-class classifier. The results remained robust despite extensive image augmentation. For 3/5 classifiers the results remained identical; detection of incomplete and too loose LNFs showed a slight decline in predictive power.ConclusionThis experimental study demonstrates that an AI/CV algorithm can effectively detect VQIs in digital images of Nissen fundoplications. This proof of concept does not aim to test clinical Nissen fundoplication, but provides experimental evidence that AI/CV models can be trained to classify various laparoscopic images of surgical configurations. In the future, this concept could be developed into AI based real-time surgical support to enhance surgical outcome and patient safety

Recommendations of procedures to follow in the case of ovarian lesions in girls

This study presents current recommendations of the Polish Association of Pediatric Surgeons (PTChD) regarding diagnostics and treatment of ovarian lesions in girls. They are based on many years of the authors’ clinical experience as well as a review of international literature and include practical clinical guidelines. The recommendations were formulated in cooperation with the Polish Association of Pediatric Oncology and Hematology (PTOHD), Polish Pediatric and Adolescent Gynecology Section of the Polish Society of Gynecologists and Obstetricians (PTG) and Polish Pediatric Section of the Polish Society of Radiology (PLTR). Only better understanding of prepubertal ovarian biology and natural history of its pathology may help to introduce efficient and safe diagnostic and therapeutic strategies for girls. The prepared document has been supplemented with treatment algorithms.

Neuroendocrine neoplasms of the small intestine and the appendix — management guidelines (recommended by the Polish Network of Neuroendocrine Tumours)

W pracy przedstawiono uaktualnione polskie zalecenia postępowania z chorymi na nowotwory neuroendokrynne (NEN) jelita cienkiego i wyrostka robaczkowego. Jelito cienkie, a przede wszystkim jelito kręte jest miejscem najczęstszego występowania tych nowotworów. Większość z nich to nowotwory wysokozróżnicowane i wolno rosnące. Rzadko są to nowotwory niskozróżnicowane, szybko rosnące o niekorzystnym rokowaniu. Ich objawy mogą być nietypowe, a rozpoznanie przypadkowe. Typowe objawy zespołu rakowiaka występują w mniej niż 10% przypadków. W diagnostyce laboratoryjnej najbardziej przydatne jest oznaczenie stężenia chromograniny A, badanie stężenia kwasu 5-hydroksyindolooctowego jest pomocne w monitorowaniu zespołu rakowiaka. W obrazowaniu stosuje się ultrasonografię, tomografię komputerową, rezonans magnetyczny, kolonoskopię, wideoendoskopię kapsułkową, enteroskopię dwubalonową, scyntygrafię receptorów somatostatynowych. Szczegółowe badanie histologiczne jest kluczowym dla właściwego rozpoznania i leczenia chorych z NEN jelita cienkiego i wyrostka robaczkowego. Leczeniem z wyboru jest postępowanie chirurgiczne, radykalne lub paliatywne. W leczeniu farmakologicznym czynnych i nieczynnych hormonalnie NEN jelita cienkiego i wyrostka robaczkowego podstawowe znaczenie mają analogi somatostatyny. Terapia radioizotopowa u chorych z dobrą ekspresją receptorów somatostatynowych stanowi kolejną opcję terapeutyczną. Chemioterapia jest na ogół nieskuteczna. U pacjentów z rozsianym NEN jelita cienkiego i progresją choroby oraz nieskutecznością innych metod terapii można zastosować ewerolimus. Przedstawiono także zalecenia odnośnie monitorowania chorych z NEN jelita cienkiego i wyrostka robaczkowego. (Endokrynol Pol 2013; 64 (6): 444–493)We present revised Polish guidelines regarding the management of patients harbouring neuroendocrine neoplasms (NENs) of the small intestine and appendix. The small intestine, especially the ileum, is the most common origin of these neoplasms. Most of them are well differentiated with slow growth. Rarely, they are less differentiated, growing fast with a poor prognosis. Since symptoms can be atypical, the diagnosis is often accidental. Typical symptoms of carcinoid syndrome occur in less than 10% of patients. The most useful laboratory marker is chromogranin A; 5-hydroxyindoleacetic acid is helpful in the monitoring of carcinoid syndrome. Ultrasound, computed tomography, magnetic resonance imaging, colonoscopy, video capsule endoscopy, balloon enteroscopy and somatostatin receptors scintigraphy are used in the visualisation. A histological report is crucial for the proper diagnostics and therapy of NENs, and it has been extensively described. The treatment of choice is surgery, either radical or palliative. Somatostatin analogues are crucial in the pharmacological treatment of the hormonally active and non-active small intestine NENs and NENs of the appendix. Radioisotope therapy is possible in patients with a good expression of somatostatin receptors. Chemotherapy is not effective in general. Everolimus therapy can be applied in patients with generalised NENs of the small intestine in progression and where there has been a failure or an inability to use other treatment options. Finally, we make recommendations regarding the monitoring of patients with NENs of the small intestine and appendix. (Endokrynol Pol 2013; 64 (6): 480–493

Nowotwory neuroendokrynne trzustki — zasady postępowania (rekomendowane przez Polską Sieć Guzów Neuroendokrynnych)

We present revised diagnostic and therapeutic guidelines for the management of pancreatic neuroendocrine neoplasms (PNENs) proposed by the Polish Network of Neuroendocrine Tumours.These guidelines refer to biochemical (determination of specific and nonspecific neuroendocrine markers) and imaging diagnostics (EUS, CT, MR, and radioisotope examination with a 68Ga or 99Tc labelled somatostatin analogue).A histopathological diagnostic, which determines the further management of patients with PNENs, must be necessarily confirmed by immunohistochemical tests. PNENs therapy requires collaboration between a multidisciplinary team of specialists experienced in the management of these neoplasms. Surgery is the basic form of treatment. Medical therapy requires a multidirectional procedure, and therefore the rules of biotherapy, peptide receptor radionuclide therapy, chemotherapy and molecular targeted therapy are discussed. (Endokrynol Pol 2013; 64 (6): 459–479)W niniejszej publikacji przedstawiono zaktualizowane zalecenia dotyczące diagnostyczno-terapeutycznego postępowania w nowotworach neuroendokrynnych trzustki (PNEN) zaproponowane przez Polską Sieć Guzów Neuroendokrynnych.Dotyczą one diagnostyki biochemicznej (oznaczanie specyficznych i niespecyficznych markerów neuroendokrynnych) i lokalizacyjnej (z uwzględnieniem EUS, CT, MR, scyntygrafii receptorów somatostatynowych z użyciem analogów znakowanych 68Ga lub 99Tc).Duże znaczenie ma rozpoznanie histopatologiczne, które determinuje dalsze postępowanie z chorymi na PNEN i musi być potwierdzone badaniem immunohistochemicznym.Terapia PNEN wymaga współpracy wielodyscyplinarnej grupy doświadczonych specjalistów zajmujących się nowotworami neuroendokrynnymi. Leczenie chirurgiczne jest postawową metodą postępowania. Dalsza terapia wymaga wielokierunkowego działania, dlatego omówiono zasady bioterapii, leczenia izotopowego, chemioterapii oraz celowanego leczenia molekularnego. (Endokrynol Pol 2013; 64 (6): 459–479

Nowotwory neuroendokrynne żołądka i dwunastnicy z uwzględnieniem gastrinoma — zasady postępowania (rekomendowane przez Polską Sieć Guzów Neuroendokrynnych)

This paper presents the updated Polish Neuroendocrine Tumour Network expert panel recommendations on the management of neuroendocrine neoplasms (NENs) of the stomach and duodenum, including gastrinoma. The recommendations discuss the epidemiology, pathogenesis and clinical presentation of these tumours as well as their diagnosis, including biochemical, histopathological and localisation diagnosis. The principles of treatment are discussed, including endoscopic, surgical, pharmacological and radionuclide treatment. Finally, recommendations on patient monitoring are given. (Endokrynol Pol 2013; 64 (6): 444–458)W niniejszej pracy przedstawiono uaktualnione zalecenia grupy ekspertów Polskiej Sieci Guzów Neuroendokrynnych dotyczące zasad postępowania w nowotworach neuroendokrynnych żołądka i dwunastnicy z uwzględnieniem gastrinoma. Omówiono epidemiologię, patogenezę i obraz kliniczny tych nowotworów. Przedstawiono zalecenia dotyczące zasad postępowania diagnostycznego, z uwzględnieniem diagnostyki biochemicznej, histopatologicznej oraz lokalizacyjnej. Uwzględniono także zasady postępowania terapeutycznego, w tym leczenie endoskopowe i chirurgiczne, oraz omówiono możliwości leczenia farmakologicznego i radioizotopowego. Przedstawiono także zalecenia odnośnie monitorowania chorych z NEN żołądka, dwunastnicy z uwzględnieniem gastrinoma. (Endokrynol Pol 2013; 64 (6): 444–458

Colorectal neuroendocrine neoplasms — management guidelines (recommended by the Polish Network of Neuroendocrine Tumours)

Nowotwory neuroendokrynne (NENs) jelita grubego stanowią 20% wszystkich nowotworów neuroendokrynnych. Najczęstszą ich lokalizacją jest odbytnica. Nowotwory neuroendokrynne jelita grubego są wykrywane coraz częściej i liczba ta będzie wzrastać z uwagi na powszechność wykonywania kolonoskopii, w tym badań przesiewowych oraz usuwanie wykrytych zmian. W pracy przedstawiono aktualne zalecenia dotyczące diagnostyki i terapii NEN jelita grubego, z uwzględnieniem diagnostyki biochemicznej, patomorfologicznej, nowych technik obrazowania oraz leczenia endoskopowego, chirurgicznego, farmakologicznego i radioizotopowego. Omówiono także epidemiologię, charakterystykę kliniczną i monitorowanie leczenia. (Endokrynol Pol 2013; 64 (6): 494–504)Neuroendocrine neoplasms of the large intestine account for 20% of all neuroendocrine neoplasms (NENs) and are most commonly found in the rectum. The rate of detection of colorectal NENs is increasing, and this tendency will continue due to the widespread use of colonoscopy as a screening tool and the removal of all diagnosed lesions. This paper provides updated guidelines for the management of patients with colorectal NENs. Recent data on epidemiology, clinical characteristics, biochemical, and pathomorphological diagnosis as well as useful imaging techniques are presented. We look in detail at novel methods of treatment including endoscopic and surgical management, pharmacological and radioisotope therapy. We summarise monitoring of the treatment. (Endokrynol Pol 2013; 64 (6): 494–504